Assessment of cardiovascular disease

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Assessment of cardiovascular disease

• Dr.Kasem Ratanasumawong

19 Feb 2003
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Assessment ?

• Assessment for diagnosis
• Assessment for disease severity and prognosis

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Cardiovascular disease ?

• Endocardium valvular heart disease, infective
  endocarditis
• Myocardium Ischemic heart disease,
  myocarditis/cardiomyopathy
• Pericardial disease pericarditis, pericardial
  effusion
• Disease of aorta aortic aneurysm, aortic
  dissection

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Cardiovascular disease ?

• Ischemic heart disease / Acute myocardial
  infarction
• Congenital heart disease (??????????????????????)
• Valvular heart disease / Rheumatic heart disease
• Cardiac arrhythmias (?????????????????????)
• Hypertension (??????????????????)

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Assessment of CVD

• ???????????????????????????
• ????????????????????????????????
• ???????????????????????????????

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????????????????

• ?????????????? Angina -gt Ischemic heart
  disease, Acute MI
• ??????????? Dyspnea ????????????????? NYHA
  functional class
• ???????, ??????, ??????, ?????? -gt cardiac
  arrhythmias

7
Chest pain Classic
angina - a dull,substernal discomfort -
radiate to left arm or neck - associated with
shortness of breath, palpitations,
sweating, N/V
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Typical angina (definite)

• Substernal chest discomfort with a characteristic
  quality and duration that is
• provoked by exertion or emotional stress
• relieved by rest or nitroglycerine

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Atypical angina ( probable ) meets 2 of the
above characteristicsNoncardiac chest pain
meets lt 1 of the typical angina characteristics
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Grading of angina pectoris CCS Classification

• Class I Ordinary physical activity does not
  cause angina
• Class II Slight limitation of ordinary
  activity
• Class III Marked limitations of ordinary
  activity
• Class IV Inability to carry on any physical
  activity without discomfort

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??????????????

• Cardiac heart
• vascular blood pressure and arterial pulse
• General appearance
• Basic knowledge Skill important

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Heart examination

• ??-???-????-???
• PMI ( point of maximal intensity )
• Heave, thrill
• S1, S2, gallop, click
• heart murmur systolic diastolic, location,
  grading, radiation
• pericardial rub

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Blood pressure

• Sphygnomanometer
• Dx of Hypertension / shock
• Hypertension BP gt 140/90
• Pitfall of blood pressure measurement
• Dx of pulsus paradoxus

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Arterial pulse

• Location Radial, brachial, carotid, femoral,
  popliteal, dorsalis pedis
• Rhythm Sinus rhythm, Atrial fibrillation,
  Ectopic beat/PVC
• Intensity Bounding pulse, Collapsing pulse,
  Pulsus alternan
• Peripheral pulse / carotid bruit / abdominal
  bruit
• Eye ground Hypertensive retinopathy

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Venous pulse

• Internal jugular engorged neck vein, ? cm
  above sternal angle at 45 degree position
• Internal jugular giant V wave, intermittent
  cannon A wave, Kussmual sign

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General appearance

• Congenital anomaly Down syndrome, Turnor
  syndrome, Noonan syndrome
• Marfan syndrome
• Cyanosis, clubbing finger

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Abnormal physical signs in absent of clinical
heart disease

• PAC,PVC
• Systolic murmur functional murmur
• Gallop sound

In case of IHD, Cardiac arrhythmias Physical
examination could be normal
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Physical examination

• ASD RVH,fixed split S2 and a grade 2-3/6 SEM at
  LUSB
• VSD ???????? pansystolic murmur ??????
• PDA continuous murmur ????????? thrill ??? left
  infraclavicular area

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Physical examination

• MS RV heave,S1, S2 or P2 ???????opening snap
  and diastolic rumbling murmur
• MR LV enlargement/ LV heave, pansystolic murmur
  at apex

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Physical examination

• AS systolic ejection murmur at AVA or PVA,LV
  heave, pulse ?? delay upstroke and plateau
  pulsus parvus et tardus
• AR ???????? diastolic blowing murmur ???
  peripheral sign ?????

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??????????????????????????

• Chest Xray / EKG
• Echocardiogram
• Exercise stress test / stress echo
• Nuclear imaging
• Cardiac catheterization
• Holters monitoring / Ambulatory blood pressure
  monitoring

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Chest Xray

• Cardiomegaly
• pulmonary vasculature
• Pulmonary hypertension
• Pulmonary congestion
• Shunt

ASD,VSD,MS,congestive heart failure Aortic
dissection/aneurysm
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EKG Assessment of CVD

• For Dx IHD myocardial ischemia, myocardial
  injury,myocardial infarction ( acute,recent,old
  )
• For Dx cardiac arrhythmias
• For Dx chamber enlargement hypertrophy
• For Dx pericarditis

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EKG Assessment IHD

• EKG could be normal in one-half of patients with
  chronic stable angina ( sensitivity about
  50 )
• EKG of IHD inverted T wave, ST depression,
  abnormal Q wave (old MI )
• EKG of acute MI ST elevation, inverted T and Q
  wave

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Abnormal EKG in absent of clinical heart disease

• QS complex in AVL,V1-2 . QS or QR complex in
  III,AVF.
• Tall R inV1 and V2. High voltage R wave over left
  ventricle
• ST elevation early repolarization
• Inverted T wave nonspecific T wave changes

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Abnormal EKG in absent of clinical heart disease

• Nonspecific ST and T wave changes are the most
  common EKG abnormality
• About 50 of abnormal tracings recorded in a
  general hospital population
• most common cause of iatrogenic EKG heart
  disease
• must always be correlated with all available
  clinical and laboratory information

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Information from Echocardiography

• Cardiac valves morphology chamber enlargement ,
  hypertrophy ?
• LV systolic and diastolic function regional
  wall motion abnormality
• Valves function stenosis regurgitation
• Pericardial effusion, vegetation thrombus
• congenital heart disease ASD,VSD,PDA
• Aortic dissection

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Echocardiography in IHD

• Assess global LV function and RWMA ( abnormal
  in case with old MI )
• Could be normal in chronic stable angina
• hypokinesia myocardial ischemia
• akinesia dyskinesia myocardium infarction

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??????????? EST

• For Dx IHD
• For assess IHD high / low risk
• Overall sensitivity about 75 ( negative test not
  excluded )
• Limitation in young,middle age female, abnormal
  baseline EKG ( false positive is high )

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Exercise stress test

• Specificity is less in women than men
• lower prevalence and extent of CAD in young and
  middle-aged women catecholamine effect
• LVH, LBBB, WPW syndrome need exercise or
  pharmacologic imaging study

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Exercise stress test

• Result of EST
• Positive VS Negative
• Equivocal
• Inadequate
• assess functional capacity low,moderate or high
  workload
• assess hemodynamic response

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Exercise stress test

• Assess myocardial ischemia
• In case of old MI
• EST could be positive or negative
• Negative EST not exclude old MI

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Exercise or pharmacologic stress
echocardiography

• Higher specificity
• More extensive evaluation of cardiac anatomy and
  function
• Greater convenience,efficacy and availability
• Lower cost ( compare with stress perfusion
  imaging )

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Stress perfusion imaging

• MIBI scan / Thallium
• Higher technical success rate
• Higher sensitivity
• Better accuracy in evaluating possible ischemia
  when multiple rest LV wall motion abnormalities
  are present

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Coronary angiography

• Invasive test
• Gold standard for Dx IHD
• single or double or tripple vessel disease
• Left main disease ?
• of stenosis
• Assess LV function by LV ventriculogram

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Other tests for assess CVD

• Holters monitoring assess symptoms possibly
  related to cardiac arrhythmias eg. Sick sinus
  syndrome
• Tilt table test for Dx vagovagal syncope
• Electrophysiologic study in case of cardiac
  arrhythmias
• Ambulatory BP monitoring for exclude white-coat
  hypertension
• CT scan for Dx aortic dissection

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Cardiac markers in acute coronary
syndrome/acute MI

• Cardiac troponins
• Cardiac troponin T (cTnT)
• Cardiac troponin I (cTnI)
• CK-MB
• CK-MB isoforms
• Myoglobin

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Assessment for disease severity and prognosis

• Ischemic heart disease
• congenital heart disease
• valvular heart disease
• Hypertension

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Ischemic heart disease

• ?????????????????????????
• ?????????
• ???????????????
• ???????
• ???????????????
• ?????????? / ???????????????
• ??? ??? ???? gt 45 ?? ???????? gt 55??

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Spectrum of disease

• Silent ischemia
• Chronic stable angina
• Acute coronary syndrome
• Unstable angina
• Acute nonST elevation MI / NQWMI
• Acute ST elevation MI / QWMI

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Prognosis

• ??????????????? ?????????
• ?????????????????????????????????????????
  ??????????????????????????? ( CHF ) ???
• ????????????????????????????????? ??? Acute MI,
  CHF, Cardiac arrhythmias
• ????????????????????????????????????
  ????????????????

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Prognosis of chronic stable angina

• ?????????????????????????????? noninvasive test
  ???????????????????????? 3 ?????
• high risk gt 3 annual mortality rate
• intermediate risk 1-3 annual mortality rate
• low risk lt 1 annual mortality rate

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Prognosis of unstable angina

• Variable prognosis
• 57 developed an adverse event ( acute
  coronary syndrome ) during 8 months
• in hospital mortality about 1.5 , 1 year
  mortality about 9.2
• need risk stratification for further Rx

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Prognosis of Acute MI

• In hospital mortality about 17
• 1 year mortality about 27
• Predictor of outcome
• LV function
• Residual ischemia
• Electrical instability

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Death from MI

• Pre hospital 52
• In hospital 24 hours 19
• In hospital 48 hours 8
• 30 days 21

Over all mortality 30 10-15 by CCU
monitor,defibrillator 5-10 in myocardial
reperfusion era
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Common congenital heart disease in adult

• Atrial septal defect
• Ventricular septal defect
• Patent ductuc arteriosus
• Tetralogy of fallot
• Coarctation of aorta

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Atrial septal defect

• ????????????
• ???????????? ??????????? secondum ????????????? (
  3-8 mm ) ?????????????????? ( ???? lt 11/2 ?? )
• ?????????????? ?????? pulmonary hypertension, RV
  failure
• ??????????? AF ??? cerebrovascular accident ???

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Ventricular septal defect

• ????????????
• small membranous VSD ?? spontaneous closure ???
  30-40 ????? 6 ?????
• ??????? large VSD ?????? pulmonary hypertension (
  Eisenmengers syndrome ???????
• ???? infective endocarditis ???

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Common valvular heart disease

• Mitral stenosis ( MS )
• Mitral regurgitation ( MR )
• Aortic stenosis ( AS )
• Aortic regurgitation ( AR )

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Mitral regurgitation

• ???????????? -gt ????????????????????
  ?????????????????????????? 90 ????? 10 ??
• ????????????? ?????????? 10 ?? ??????? 32 - 72

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Aortic stenosis

• ???????????? ???????????????????????????????????
  ?????????
• ??????????????????? sudden death ???
• Life expectancy
• 5 ?? ????????????????????
• 3 ?? ?????????? syncope
• 2 ?? ?????????? ??????? CHF
  

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Aortic regurgitation prognosis

• Asymptomatic , normal LV systolic function
• Progress to symptom and/or LVD lt 6/year
• progress to asymtomatic LVD lt 3.5/year
• sudden death lt
  0.2/year
• Asymptomatic , LV dysfunction
• progress to cardiac symptom gt 25/year
• Symptomatic mortality rate gt
  10/year

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Hypertension

• Definition
• systolic blood pressure gt 140 mmHg and/or
  diastolic blood pressure gt 90 mmHg
• ??????????????????????????
• ???????? primary ( Essential ) hypertension ????
  secondary hypertension

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Hypertension

• ????????????????????????????????
• ?????????? ?????????????????. ????????????????
• ????????? ?????????????????? ????
  ??????????????????
• ??????? ?????????????

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Hypertension

• Grade 1 mild HT 140-159/90-99
• Grade 2 moderate HT 160-179/100-109
• Grade 3 severe HT gt180/ gt110
• Isolated systolic HT gt140/ lt90

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Hypertension

• Risk stratification
• Low risk risk for CVD event lt 15 in 10 year
• medium risk risk for CVD event 15-20 in 10
  year
• high risk risk for CVD event 20-30 in 10 year
• Very high risk risk for CVD event gt 30 in 10
  year